of Current Schizophrenia
Therapy in the United States and Japan
This paper compares current therapies for schizophrenia in the United States and Japan. It discusses how cultural background, psychodynamics, and family therapy can influence the care of schizophrenia patients. Nursing interventions are examined. A conceptual model comparing current schizophrenia therapies in the United States and Japan is originated (Figure 1).
Comparison of Current Schizophrenia Therapy in the United States and Japan
Schizophrenia is a chronic mental illness that presents in hallucinations, delusions, disorganized or catatonic behavior, or disorganized speech (Diagnostic and Statistical Manual of Mental Disorders DSM- IV, 1994). It comprises the largest group of mental disorders, and exists across all cultures and socioeconomic groups (Fortinash & Holoday- Worret, 2000). Due to the often severe nature of the illness, most persons with schizophrenia (PWS) require an extended range of supportive services (McFarland, Wasli, & Gerety, 1992).
This writer has come in contact with PWS during psychiatric clinical rotations in both the U.S.A. and in Okinawa, Japan. During the course of these experiences, it was noticed that while the cultural and environmental settings of schizophrenic patients may differ, patients demonstrate almost identical symptoms. Also, while there are similarities in theory and treatment modalities, some differences exist in the manifestation, recognition and treatment of the disease. As the author will note, Okinawan practice in particular has its own unique approach that differs from those of both the U.S.A. and mainland Japan.
Current theoryIn Japan and in the U.S.A, the current causative theories of schizophrenia generally follow the same line of thought. In both countries, the primary causes of schizophrenia are considered to be physiological factors, including genetics and abnormal neurotransmitter function (Nakane, Ohta, & Redford, 1992). Although it is an illness that is still relatively poorly understood, in part because of its complexity, it is also becoming increasingly clear that it is a disorder that is strongly influenced by stress (Wuerker, 2000).
American researchers have postulated a heredity model that states that the lifetime risk of developing schizophrenia when one has a close relative with schizophrenia is much higher thanfor individuals within the general population. Another proposal, the dopamine theory, states that too much dopamine contributes to schizophrenia (Fortinash & Holoday-Worret, 2000).
Japanese research has followed similar lines. For example, Japanese psychiatric researchers, Kunugi, Takei, Saito, Akizuki, and Murray (1996), have shown that schizophrenics have delayed cerebral developments in utero, and that in addition to some environmental factors, genes which operate on prenatal neurodevelopment may also be involved in this impaired brain growth. Japanese researchers have reported decreased serotonin S2 receptors and increased dopamine D2 receptors in the frontal cortices of chronic PWS (Utena & Niwa, 1992).
Therapy for Schizophrenia
In both countries, most treatment falls into the categories of pharmaceutical, psychological and psycho-educational therapies.
In both Japan and the U.S.A., psychopharmacology is the somatic treatment of choice for schizophrenia. The effectiveness of antipsychotic drugs in maintenance therapy for schizophrenia has been established by numerous studies in both the U.S.A. and Japan. Such drugs decrease extraneous stimuli, thereby strengthening the clients contact with reality, making them more amenable to various forms of social, recreational, and rehabilitative therapies. However, while these drugs reduce a wide range of symptoms very effectively, especially over the short term, they do not maintain effectiveness over some of the symptoms of chronic schizophrenia, such as flat affect. Also, they do not seem to significantly affect the quality of the clients social or personal adjustment to life outside of the hospital (Johnson, 1993).
The choice of any psychotropic medication depends on its effectiveness and its safety for the individual client. Most PWS are helped by antipsychotic medications; some are unaffected
and some become worse (Johnson, 1993). Hahlweg and Wiedemann (1999) and Munich (1997) research showed that psycho-educational family management in combination with medication proved to be highly effective in preventing relapse in schizophrenia.
In the U.S.A., electroconvulsive therapy (ECT) is sometimes used when psychotic symptoms fail to respond to pharmacotherapy alone (Leff, 1992). In Japan, ECT is used much less often because it is associated with punishment (Kramer & Pi, 1990).
In combination with pharmacotherapy, cognitive therapy or psychological approach is used. This typically includes group therapy, counseling, and teaching activities of daily living skills. This therapy generally focuses on understanding and accepting the illness, addressing patient concerns with the loss of function, and beginning self-management of the illness (Munich, 1997).
Psycho-education and Family therapy
Family therapy plays a major role in the psycho-educational treatment of PWS. In the U.S.A., it has been acknowledged that when the PWSs family members participate even only minimally in the patients therapy, they are important in assuring the success of clinical treatment (Bustillo, Keith, & Lauriello, 2000). There have been studies that compared family therapy to individual therapy, the results of which have been overwhelmingly in favor of family therapy (Buchanan & Carpenter, 2000). Families can be active members of the clinical treatment team, and provide information about the patients progress as well as ensuring medication compliance (Fortinash & Holoday-Worret, 2000).
While the concept of family therapy and support of the PWS is acknowledged as being important in the U.S.A., its actual use in practice seems to be more prevalent in Japan. Yamashita (1996, 1997) has shown that in Japan the main source of support for PWS comes
from their immediate family members. Additionally, during discussions in family therapy sessions, spirituality has been identified as a main support of caregivers through the sharing of both experiences and coping techniques (Yamashita, 1996).
In the U.S.A., there has been some criticism of the family therapy approach to treatment of the PWS. The U.S.A. professionals generally feel that the family should not be seen as a long-term caregiver or therapist, pointing to issues such as caregiver "burnout" and resultant likelihood of patient relapse (Sanders, 1999). In Japan, these issues have also been recently addressed. Japans Mental Health Law of 1998 was designed to address the drawbacks of the hoghosha system, a society-driven and traditional system in which the guardian of the PWS, typically the parents, spouse, or siblings, has custody of the patient. Japanese critics, much as their American counterparts, point to issues of caregiver burnout, and the hogoshas powers infringing on the patients human rights (Shiraishi, 1994).
In addition to such concerns, the rapid Westernization and industrialization of Japan have resulted in an increasingly nuclear family unit, which has resulted into breakup of extended families and the decline of support systems for the PWS that such structures traditionally provided in Japan. This, combined with the increasing need for all family members to work to maintain a certain standard of living, has resulted in the necessity of reevaluating the familys role in providing care for the PWS (Matayoshi, 1996, Ushijuma, 1998).
Family and Folk Therapy in Okinawa, Japan
In the Okinawa prefecture of Japan, the family is actually considered to be the first source of mutual help and support for the PWS. The ties within the Okinawan family are strong, and easily run through three generations. The problem of one family member is usually regarded as being a problem of the whole family, and all the family members unite to deal with any given situation. This cultural characteristic of Okinawans offers many advantages. The strong family and social ties provide the security, care, and emotional and material support that are very much needed by the discharged chronically ill PWS (Matayoshi, 1996).In Okinawa there is a unique "ethno-medicine" family therapy, which is practiced by a therapist/healer known as a "Yuta." The Yutas role is primarily an advisor who closely relates to the patients daily life, providing spiritual counsel concerning health problems and general counsel for mental health matters (Naka, Takaishi, Ishizu, and Sasaki, 1983). One example is that the Yuta uses the examination of a patients family tree to identify a mental illness in the patients ancestors, so as to make the PWS aware of this connection. By doing so, the family member and the client see schizophrenia as an inherited family problem, rather than as an individuals behavioral problem (Matayoshi, 1996). This therapy is effective because it takes into full consideration the cultural, societal, and personal needs of the PWS. The Yutas credentials are totally reliant on reputation rather than education, a factor that seems to reduce patient/therapist boundaries; the PWS therefore feels more relaxed and less distanced from the advice that they are receiving. A conceptual model of current comparison therapy for a PWS in the U.S.A. and Japan is presented (Figure 1). Cultural diversity in the U.S.A. and Japan are shown, as well as differences and similarities in patient management.
Discussion: Nursing Intervention
The nursing interventions for PWS in the U.S.A. and in Japan are generally similar. The author recognizes that in consideration of the U.S.A. model of nursing, the entire burden of care must not fall on the family, as mentioned above. This means that the nurse has an important support role to play in the care of the PWS. However, the author also has experienced the value of the Okinawan system of family support; this emotional and material support has proven unquestionably valuable in the successful care of countless PWS.
It is important to acknowledge that ongoing family support helps to improve family problem solving, to lower the family burden, and to ensure patient compliance with medication and rehabilitation (Munich, 1997). Nurses can contribute to this support through advocacy efforts that work toward reducing family stress to ensure a range of appropriate and available services for clients and their families (Johnson, 1993).
Although the U.S.A. and Japan have different cultural backgrounds and environments, PWSs families continue to represent the largest number of care providers in both countries. In the nursing profession, nurses can learn something from cross- cultural education. By recognizing the value of culture-based therapies such as those practiced by the Yuta in Okinawa, health professionals can enhance the type of care currently practiced. It is the authors opinion that professional therapists must not forget the value of family, spiritual, and ethnic treatment modalities. By integrating modern and traditional therapies of different societies and cultures into a more holistic approach, we can meet the global challenges to mental health care as we enter a new world economy.
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